Research Commentary [28] February 2019

Feb 12, 2019

This review focuses on cultural factors impacting on access and the use of mental health service by Asian young people and their family.

A New Zealand study of Child and Adolescent Mental Health Services (CAMHS) cites cultural barriers for Asian families accessing CAMHS (Appleby & Phillips, 2013). While 3 per cent is considered the appropriate general access rate for CAMHS, Asian groups although growing have the lowest rate of access of all ethnic groups in 2015 (0.75%) (The Werry Workforce ‐ Whāraurau, 2017). The studies reviewed show that cultural explanatory models of mental illness that differ from western biomedical models, along with stigma about attending mental health services are major factors in family reactions and responses to mental health and illness.

Mental health issues are increasingly evident in Asian young people in New Zealand and international studies (Islam et al., 2017; Jacob et al., 2013; The Werry Workforce ‐ Whāraurau, 2017). The need for the delivery of culturally competent health care and mental health services is paramount. Child and Adolescent Mental Health Services which incorporate a culturally competent framework that includes the use of the CALD cultural competence model for practice, can guide health care providers in the recognition of mental health problems in Asian children, youth and families.

Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development

The following articles are reviewed:

Article 1: The Asian American Family and Mental Health: Implications for Child Health Professionals

This article will assist health care professionals to provide culturally appropriate mental health care for Asian youth and their families. An overview of research in the past two decades shows that Asian American students have high levels of social anxiety when compared with European American students, although their distress is not readily evident to those who observe them. Issues related to acculturation and intergenerational issues have been associated with high stress, which negatively affects mental health.

Asian parents view their child’s achievements as the pride of the family; a child’s failure is considered as shaming the family. The drive for academic and career achievement coincides with family honour. Asian American children are taught that they have a responsibility toward maintaining their family’s positive image; this belief may make them reluctant to seek any kind of professional help and choose to keep their personal struggles secret.

In the article, the table comparing Eastern and Western cultural values; and the cultural awareness case study, are particularly useful for improving cultural assessment skills, intervention and cross-cultural communication when working with young people and families. For example, it is important to identify the decision-makers for the family. Extended family members such as grandparents, aunts, uncles, and other relevant caretakers tend to have a strong influence on an Asian child’s upbringing. As well, understanding that Asian clients may be more likely to describe physical symptoms rather than report mental distress may lead health practitioner’s to define and clarify the meaning of the presenting problem with the client.

During engagement and therapeutic intervention, the authors emphasise the importance of keeping parents as close to their children as much as possible (unless there is suspected danger), and to respect their power. Acknowledgement of family strengths and their efforts and good intentions is important. If parents believe that the clinician is working with them rather than against them, tensions can be lowered and effective care given. As trust in the therapeutic process develops, it is important to redirect parent’s attention away from the shame and guilt they may place on their children when they do not behave as expected. Goals must be identified and broken into manageable small steps. Finally, a point of connection must be reached where parents and children can be encouraged to express positive emotions with each other to help move them forward. The next article in this review explores the area of engaging parents in more detail.

Article 2: Mental health of South Asian youth in Peel Region, Toronto, Canada: a qualitative study of determinants, coping strategies and service access.

This qualitative study provides youth perspectives on the mental health challenges and service access barriers experienced by South Asian youth populations in the Peel Region of Toronto, Canada. In-depth semi-structured interviews with South Asian youth showed that they face many mental health stressors, from intergenerational and cultural conflict, academic pressure, relationship stress, financial stress and family difficulties. These stressors can contribute to mental health challenges, such as depression and anxiety and drug use, with marijuana, alcohol and cigarettes cited as the most popular substances. South Asian youth did not feel well informed about mental health resources available in their neighbourhood. The recommendations that South Asian youth offer for: improved youth support directed at parents; the education system; South Asian communities; and the mental health system, are particularly insightful, useful and relevant to informing improved mental health support for South Asian youth in New Zealand.

Firstly, the interviews highlight the need to recognise that each sub population of youth faces unique challenges to their mental health. For example, Muslim immigrant youth may face cultural and religious discrimination and stereotyping. On the other hand, stressors such as peer relations, lack of attention from parents and parental pressure to succeed were identified for Punjabi Sikh youth. Conflicts with parents continually emerged as a major mental health stressor for South Asian youth, with migration and resettlement as the underlying cause of the intergenerational and culture clash between parents and youth. Youth suggested that more open dialogue, perhaps with role-playing, where both youth and parents can effectively express their positions, would greatly help in mitigating these conflicts. They suggested that adaptations to parenting programmes for newcomer parents and adolescents was needed.

The youth in this study spoke about the far-reaching impact of their mothers’ untreated depression, particularly postpartum depression (PPD). The depression often made it difficult for mothers to parent effectively, and this in turn affected young people’s mental health. Intergenerational mental health interventions may be particularly helpful in this regard. The 8-week parenting programme SITICAF (Strengthening of Intergenerational/Intercultural Ties in Immigrant Chinese American Families) is a recommended approach (Ying, 2009). The programme, one of the few empirically tested interventions to address this problem is a culturally sensitive, community-based intervention that aims to strengthen the intergenerational relationship. It promotes immigrant parents’ emotional awareness and empathy for their children’s experiences, cognitive knowledge and understanding of differences between their native and western cultures, and teaches behavioural parenting skills with the objective of enhancing intergenerational intimacy.

Youth called for culturally safe models of mental healthcare that respected South Asian beliefs and practices. South Asian youth also felt that beyond ‘cultural sensitivity training’ capacity needs to be built in order to increase the number of South Asian and other ethnic minority mental health professionals. In addition, they suggested that Multicultural Mental Health information needed to move beyond the simple translation of mental health information to cultural adaptation of resource information and increased representation of ethnic minorities within mental health promotion material.

Article 3: Management of a Mental Health Crisis in an International High School Exchange Student: A Case Study.

Acculturative stress is a significant problem for international students in the US and in other countries, and has been associated with a variety of psychiatric symptoms and psychosocial impairment. This literature review focuses on the mental health issues of International students from East Asia (China, Hong Kong, South Korea, Japan) who typically are dealing with differences in culture as well as high expectations for academic success.

International students need some level of preparation for the different social customs and behavioural expectations, relationship and communication differences, academic performance expectations, and daily living customs of the host nation and their particular host family. Added supports such as host family training programmes and peer buddy programmes have also found to be helpful in reducing the effect of culture shock. Additionally, CAMHS in the regions where international students are settled need to be culturally competent to provide mental health support for international students facing acculturative and psychological stresses and where necessary to assist with planning for assessment, clinical stabilisation, and the return home of international students who may face mental health crises

The authors present a case study of a Chinese high school student who attempted suicide during his education in the United States. The case study and the review of the client’s, (a 17 year old male Chinese student), acculturation difficulties and their impact on his mental health highlight the difficulties that may be experienced by the high school level international students in New Zealand. Ensuring as many social and emotional supports for students as possible is paramount. The need for culturally competent care that is responsive to cultural, clinical, and developmental/social support needs is essential in responding to the mental health difficulties of CALD youth, but particularly for youth who are visitors to a new culture.

Members of the treatment team in this case utilised a cultural consultant effectively. They considered the unique needs that an international student would face, such as stigma around mental illness and suicidality in his home community, shame around the perceived failure of his academic programme, and care coordination needs in transitioning his care to providers in his home nation. Strong advocacy was required in ensuring appropriate transportation back to his homeland.

This case provides a comprehensive overview of the sociocultural issues related to working with international students of secondary school age. In order to serve such students effectively, providers should be willing to implement elements of culturally competent care, such as obtaining cultural consultation, utilising broad cultural resources, modifying treatment techniques to effectively address clinical and cultural needs, and coordinating care with colleagues from the home nation across very different systems of care. Secondary schools which offer places for international students must also be able to respond to and prevent the adverse effects of mental health crisis in their students.

This study focused on Chinese sexual/gender minority youth in New Zealand. It sought to explore features they found challenging or supportive of their mental health and wellbeing. Semi-structured interviews were conducted with 11 Chinese sexual/gender minority participants aged between 19 and 29 years old residing in Auckland.

Two major domains of findings emerged. Firstly, participants described mental health challenges linked to racism, sexism, cis-heteronormativity (The assumption that all human beings are cisgender, ie have a gender identity which matches the sex they were assigned at birth) and challenges in relation to intersecting identities. Among participants, women faced additional challenges owing to the pervasive nature of sexism. Secondly, Chinese culture and community connections, family and peer support and role models seemed to facilitate resiliency. However, the fear of ‘losing face’, unwillingness to disclose distress when unwell and mental health service providers’ lack of cultural and linguistic competency were described as barriers to effective mental health support.

In line with the literature, while adopting the language and behaviours of the host culture is generally thought to improve wellbeing, this study shows that retaining a bond with one’s own ethnic culture appeared to assist participants in fostering a strong sense of self. Mental health organisations, educators and other service providers who work with ethnically diverse youth may have an important opportunity to invest in diversity programmes that can support young people to explore and utilise their own cultural resources for resilience. Also, as role models can become ‘a source of pride, inspiration, and comfort’ for Chinese sexual/gender minority youth, mental health managers and policy makers could consider ways to train more culturally diverse and sexual/gender minority professionals in the field.

Two pertinent options appear to exist to support mental health service provision for these young people. Culturally attuned therapies are recommended that combine Western psychotherapeutic or counselling models with Chinese philosophies. These may address participants’ dissatisfaction with the cultural competence of practitioners. Furthermore, as many participants reported accessing the internet, free online self-help tools (e.g. Rainbow SPARX for sexual/gender minority youth) (Merry et al. 2012; Lucassen et al. 2015) may be helpful and mitigate the potential barriers of shame and fears about confidentiality that are discussed by participants. In conclusion, Chinese and sexual/gender minority identities were integral parts of participants’ sense of self, and this was associated with their mental health and wellbeing.